**8. The initial case-series and registries of carotid stenting**

involve stenting, used first by Théron in 1990 and then widespread use of cerebral protection devices.

**8. The initial case-series and registries of Carotid stenting** 


**Table 2.** Carotid Stent Series [8]

1.2%, 1.3%, and 1.7% at 1, 2, and 3 years, respectively.[9]

1. Class-III/IV congestive heart failure

2. Left ventricular ejection fraction<30%

3. Open heart surgery within 6 weeks

5. Unstable angina: class III/IV

4. Recent myocardial infarction (>24 h <30 d)

6. Concurrent requirement for coronary revascularization

**9. Results of multicenter registries** 

Table 2. Carotid Stent Series [8]

of stenosis. This observation was assumed to be attributable to a lack of statistical power of the trials. The benefit from CEA relates to the complication rates. Reported benefits were predicated on operative risks of stroke or death of 7.5% in the ECST and 6.5% in the NASCET. If the disabling stroke and death rates exceed this by as little as 2%, the benefit

There have been a dramatic fall and a rise in the rates of carotid endarterectomy in both the United States and Canada, which correlate with the publication of first unfavorable and then favorable clinical studies. The absence of selective referral of patients to centers with the lowest mortality rates raises questions about whether the benefits of carotid endarterectomy in the general population are similar to those demonstrated in the clinical trials. Rates of carotid endarterectomy fell in all three regions from 1984 to 1989 (from 126 to 66 per 100,000 adults 40 years of age or older in California, from 65 to 40 per 100,000 in New York, and from 40 to 15 per 100,000 in Ontario), after the publication of studies demonstrating that the rates of complications of carotid endarterectomy were unacceptably high. However, the clinical trials of the 1990s, which showed benefit from carotid endarterectomy, were associated with a dramatic resurgence in the rates of the procedure from 1989 to 1995 (from 66 to 99 per 100,000 in California, from 40 to 96 per 100,000 in New York, and from 15 to 38 per 100,000 in Ontario). These increased rates were not associated with proportionally greater numbers of referrals of

This NASCE, ACAS and ESCT trial as well as the spread of carotid endarterectomy worldwide unveiled the problems and limitations inherent to the procedure. It became clear that the coexistence of cardiac co-morbidity is a powerful predictor of mortality and that myocardial infarction can be the most dreaded complication, even more than stroke. This was evident, despite the fact that patients with myocardial infarction in the prior six months, congestive heart failure and patients scheduled for coronary revascularization were excluded from the large CEA trials.[6] Other limitations of the procedure were more located to the local envi‐ ronment in the neck as prior endarterectomy, prior neck dissection or radiation, cranial nerve palsies and inaccessible high/low carotid bifurcations. The presence of contra-lateral carotid

occlusion also posed a problem during cross clamping that increased the risk of CEA.

While carotid endarterectomy was growing to maturity, anther contender was born. After the fundamental work in endovascular therapy by Charles Dotter and Andreas Grüntzig, it was

**5. The spread of CEA among vascular surgeons worldwide**

patients to hospitals with low mortality rates.[5]

**7. Carotid angioplasty**

**6. The limitations of carotid endarterectomy**

from CEA disappears.[4]

108 Carotid Artery Disease - From Bench to Bedside and Beyond
